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Case Report

Endodontic management of open apex using Biodentine as a

novel apical matrix

Ambica Khetarpal, Sarika Chaudhary, Sangeeta Talwar, Mahesh Verma1

Departments of Conservative
Dentistry and Endodontics and
ABSTRACT
1
Department of Prosthodontics, Aim: Endodontic management of open apex using Biodentine as an apical matrix.
Maulana Azad Institute of
Dental Sciences, Bahadur Shah
Summary: An immature tooth with pulpal necrosis and periapical pathology imposes a great
Zafar Marg, New Delhi, India difficulty to the endodontist. Endodontic treatment options for such teeth consist of conventional
apexification procedure with and without apical barriers. Biodentine™ is new calcium silicate
based cement that exhibits physical and chemical properties similar to those described for
certain Portland cement derivatives. This article demonstrates the use of the newer material,
Biodentine as an apical matrix barrier in root end apexification procedure. This case reports
present apexification and successful healing with the use of Biodentine as an apical barrier
matrix.
Conclusion: Apexification in one step using an apical plug of Biodentine can be considered
Received : 13‑06‑13 a predictable treatment and may be an alternative to mineral trioxide aggregate apexification.
Review completed : 22‑11‑13
Accepted : 06-09-14 Key words: Apexification, apical barrier, Biodentine, periradicular healing

Mineral trioxide aggregate (MTA) has been shown to be perforations, apexification and retrograde root filling by
a very effective root filling material for sealing immature the manufacturers. A  modified powder composition, the
root canals with open apices that could otherwise impose addition of setting accelerators and softeners, and a new
technical challenges in obtaining adequate obturation. MTA predosed capsule formulation for use in a mixing device,
has an ability to facilitate periradicular healing by inducing largely improved the physical properties of this material
the hard‑tissue formation.[1] The main drawbacks of this making it much more user‑friendly with a shorter setting
class of materials so far have been slow setting kinetics and time.[5,6]
complicated handling, which rendered these technique
sensitive procedures even more difficult and restricted their Therefore, present case report highlights the nonsurgical
use to specialists.[2] management of symptomatic teeth with immature apices
and large periapical radiolucencies using Biodentine matrix
Biodentine™ is a new calcium silicate based cement of to promote periapical healing.
the same type as MTA®. It exhibits physical and chemical
properties similar to those described for certain Portland CASE REPORT
cement derivatives.[3] Its biocompatibility has also been
validated experimentally by Laurent et al.[4] Based on A 15‑year‑old male patient reported with a chief complaint
all its properties, Biodentine™ has been claimed to of pain and swelling in relation to maxillary left lateral
be a bioactive dentin substitute for the repair of root incisor. History revealed that the patient had suffered
trauma at the age of 8 years. The vitality of the tooth was
Address for correspondence: determined by the cold pulp test, using dry ice in a “pencil
Dr. Ambica Khetarpal
E‑mail: [email protected] stick” form. It revealed the negative response. Radiographic
examination revealed an immature tooth with a wide open
Access this article online apex and a radiolucent area in proximity of the apex of the
Quick Response Code: Website:
tooth  [Figure  1]. A  dentinal fin was also seen inside the
www.ijdr.in root canal. Endodontic access opening was done under
local anesthesia, and a periapical radiograph was taken to
PMID:
*** determine the working length. Biomechanical preparation
was done using no  80 K‑file using circumferential filing
DOI: motion. Root canal debridement was done using alternate
10.4103/0970-9290.142555
irrigation with 2.5% NaOCl and saline. During cleaning
Indian Journal of Dental Research, 25(4) 2014 513
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Biodentine as a novel apical matrix Khetarpal, et al.

and shaping of the canal, the dentinal fin disappeared and biocompatible material reduces leakage in the sealing
merged with the main canal. The root canal was then dried material and allows favorable response of the periodontal
with sterile paper points. Calcium hydroxide and iodoform tissues for periapical healing and apexification.
combination (Metapex™, META Biomed Co. Ltd., Korea)
was placed in the root canal, and the patient was recalled
after 1 week. One week later, the tooth was again isolated
under rubber dam, the calcium hydroxide dressing was
removed by hand instrumentation, and irrigation was
done with 1.3% NaOCl and 17% liquid EDTA Smear
Clear (SybronEndo, CA, USA). The root canal was then
dried with sterile paper points.

Biodentine capsule™ (Septodont, St. Maur‑des‑Fossés,

France) was gently tapped on a hard surface (to diffuse
powder), five drops of liquid from a single‑dose dispenser
were poured into the capsule, after which the latter was
placed in a triturator for 30 s. The mixture of Biodentine™
was hence prepared. The first increment of BioDentine
was inserted into the canal using a curved needle of the
largest diameter fitting into the canal (MAP‑system, PDSA, Figure 1: Preoperative radiograph
Vevey, Switzerland). The material was then delicately
pushed towards the apex with a root‑canal plugger. Several
increments were required to form a plug of adequate
thickness (>4 mm) [Figure 2]. The material was adapted to
the walls by applying indirect ultrasonic vibration through
an ultrasonic tip placed on the plugger touching the material.
After verifying that the material was hard‑set, and waiting
for additional few minutes, Gutta‑percha backfill was
performed using Obtura II (Texceed Co, Fenton, MO, USA.)
and the access cavity was sealed using composite resin.
A radiograph confirmed the completion of the endodontic
therapy.

A 3‑month follow‑up revealed complete periapical healing

and bone formation [Figure 3].

The clinical follow‑up at 18 months showed the patient

functioning well with no reportable clinical symptoms and Figure 2: Biodentine plug
the absence of any sinus tract formation. The radiographic
follow‑up at 18 months [Figure 4] showed complete healing
of the periapical radiolucency and regeneration of the
periradicular tissues.

DISCUSSION
Apexification is defined as ‘a method to induce a calcified
barrier in a root with an open apex or the continued apical
development of an incomplete root in teeth with necrotic
pulp’ (American Association of Endodontists 2003). The goal
of this treatment is to obtain an apical barrier to prevent
the passage of toxins and bacteria into periapical tissues
from the root canal. Technically, this barrier is necessary
to allow compaction of root filling material.[7,8] Despite
higher success rate of apical barrier formation using calcium
hydroxide, long term follow‑up is essential. Using a suitable Figure 3: Post obturation radiograph

514 Indian Journal of Dental Research, 25(4), 2014

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Biodentine as a novel apical matrix Khetarpal, et al.

being used in pulpal therapy.[4] About et al. investigated

Biodentine™ bioactivity by studying its effects on pulp
progenitor cells activation, differentiation and dentine
regeneration in human tooth cultures. The study
concluded that Biodentine™ is stimulating dentine
regeneration by inducing odontoblast differentiation
from pulp progenitor cells.[13] Laurent et al. investigated
the capacity of Biodentine™ to affect transforming
growth factor‑β1 (TGF‑β1) secretion from pulp cells and
concluded that Biodentin caused a significant increase
of TGF‑β1 secretion from pulp cells, thus inducing an
early form of dental pulp mineralization shortly after its
application.[14] Han and Okiji compared calcium and silicon
uptake by adjacent root canal dentine in the presence
of phosphate buffered saline using Biodentine™ and
Figure 4: Healing evident after 18 months ProRoot® MTA. Their results showed that both materials
formed a tag‑like structure composed of the material
Previous studies have described the disadvantages of calcium itself or calcium‑or phosphate rich crystalline deposits.
hydroxide apexification such as failure to control infection, The thickness of the Ca‑and Si‑rich layers increased over
recurrence of infection and cervical fracture.[9] time, and the thickness of the Ca‑and Si‑rich layer was
significantly larger in Biodentine™ compared to MTA after
Apexification using MTA provides an alternative treatment 30 and 90 days, concluding that the dentine element uptake
modality in immature pulpless teeth. The long setting was greater for Biodentine™ than for MTA.[15]
time of ProRoot MTA is a major shortcoming of the
material, apart from difficult handling characteristics, Kokate and Pawar conducted a study that compared
discoloration potential (gray MTA), low washout resistance the microleakage of glass ionomer cement, MTA, and
and high material cost.[2,10] Recently, various new CSMs Biodentine™ when used as a retrograde filling material
have been introduced including Biodentine (Septodont, and concluded that Biodentine™ exhibited the least
Saint‑Maur‑des‑Fosses, France). Biodentine has been microleakage when compared to other materials used.[16]
promoted as a dentin substitute which can also be used Research suggests that a high pH and released calcium ions
as an endodontic repair material. The powder component are required for a material to stimulate mineralization in
mainly consists of tricalcium silicate, with the addition to the process of hard tissue healing. Sulthan carried out a
the powder of CaCO3 and ZrO2. The liquid component has study to evaluate the pH and calcium ion release of MTA
calcium chloride (CaCl2), as setting accelerator, in the water and Biodentine™ when used as root end fillings. He
reducing agent.[4] concluded that Biodentine™ presented alkaline pH and
ability to release calcium ions similar to that of MTA.[17]
Biodentine can be used as an effective alternative to MTA The 24‑h push‑out strength of MTA was less than that of
as highlighted through this case presentation. Apexification Biodentine. Blood contamination affected the push‑out
with Biodentine requires significantly less time.[6] This bond strength of MTA Plus irrespective of the setting
can lessen the treatment time between the patient’s first time.[18] This case report emphasizes the novel approach
appointment and the final restoration. The importance of of using Biodentine to achieve single visit apexification of
this approach lies in the effective cleaning and shaping of the cases with an open apex and large periapical lesion.
the root canal, followed by apical seal with a material that The use of Biodentine has been demonstrated to induce
favors regeneration. In addition, there is reduced potential faster periapical healing for single visit apexification of
for fracture of immature teeth with thin roots, because the cases with large periapical lesions. The material is still
of immediate placement of bonded core within the root under study and many more advancements in its clinical
canal.[11] applications are expected in near future. Although the
efficacy of BioDentine as a dentin substitute is yet to be
In the present case, combination of calcium hydroxide and clinically proven for its therapeutic indications, it may be
iodoform was used as intracanal medicament for 7 days to a promising material for apexification.
make the canal dry and free from infection. Use of calcium
hydroxide for such a short term does not adversely affect ACKNOWLEDGMENTS
the fracture resistance of the tooth.[12]
The authors acknowledge the support of CSIR (Centre of Scientific
Biodentine has superior biocompatibility and sealing and Industrial Research), New Delhi. The authors do not have any
ability and is less cytotoxic than other materials currently financial relation with any of the commercial entity used.

Indian Journal of Dental Research, 25(4) 2014 515

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Biodentine as a novel apical matrix Khetarpal, et al.

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